STATE OF ILLINOIS – DEPARTMENT OF HUMAN SERVICES EMERGENCY SOLUTIONS GRANTS PROGRAM

CLIENT STATISTICS QUARTERLY REPORT

Grantee: / ______
Contract No.: / FCSTH03___(add last 3 numbers)
Report Period: (Please circle)
Report Prepared By: / Oct 14–Dec 14 Jan 15–Mar 15 April 15–June 15 Jul 15–Sept 15
______
Telephone / Email: / ______

NOTE: COMPLETE ONLY THOSE SECTIONS BELOW AS APPLICABLE FOR ACTIVITIES ACTUALLY FUNDED IN YOUR ORGANIZATION’S GRANT AGREEMENT. ALL STATISTICS BEING REPORTED HEREIN SHOULD REFLECT ONLY CLIENTS SERVED THROUGH THIS EMERGENCY SOLUTIONS GRANT AND ITS REQUIRED MATCH FUNDING.

I. Shelter Activities

A. Persons Served With Residential Assistance

(Use if Budget Includes Renovation, Operations, Essential Services and/or URA Assistance Cost Categories)

These numbers should reflect the total number of UNDUPLICATED CLIENTS HOUSED IN THIS REPORT PERIOD IN THE ORGANIZATION’S EMERGENCY OR TRANSITION SHELTER THROUGH THIS EMERGENCY SOLUTIONS GRANT. If a client served in this report period was housed and reported in a previous report period, that client should not be counted again.

Actual Number of Adults Served: ____

Actual Number of Children Served: ____

Don’t know/Refused/Other: ____

Missing Information: ____

Total ____*

Actual Number of Households Served: ____

Persons Served with Residential Assistance by Housing Type

Barracks: ____ Single Room Occupancy: ____

Group/Large House: ____ Mobile Home/Trailer: ____

Scattered Site Apartment: ____ Hotel/Motel: ____

Single Family Detached House: ____ Other: ____

Total: ____*

*Denotes they must match.

Shelter Utilization

Category / Total
Number of new units – rehabbed
Number of new units – conversion
Total number of beds – nights available
Total number of beds – nights provided

Shelter Performance Measures

Category / Total
# Entered Shelter
# Entered Case Management
# Transitioned to Permanent Housing
# Still in Shelter
# Transitioned to Non-Permanent Housing
# Refused
Total

B. Persons Served With Non-Residential Assistance

(Use if Budget Includes Essential Services Cost Category, for clients receiving an essential service, including, but not limited to: counseling, food assistance, child care, outreach, and health and/or employment services)

This number should reflect the total number of UNDUPLICATED NON-SHELTER CLIENTS SERVED IN THIS REPORT PERIOD THROUGH THIS EMERGENCY SOLUTIONS GRANT. Activities include, but are not limited to, counseling, food assistance, child care, outreach, health care, employment, etc. If a client served in this report period was reported in a previous report period, that client should not be counted again.

Total: ____

Total Persons Served with Residential and Non-Residential Shelter Assistance (Section I A & B)

Note: The numbers reported under Hispanic ethnicity should also be reflected in the Total column, as “Hispanic” denotes an ethnicity and not a race. (The federal government defines Hispanic as “a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race”.)

Race / Gender / # Total / # Hispanic
Male / Female / Transgender / Refused/Other / Missing Info
White
Black/African American
Asian
American Indian/Alaska Native
American Indian/Alaska Native & White
Asian & White
Black/African American & White
American Indian/Alaska Native &
Black/African American
Other Multi-Racial
Total - this total should match unduplicated actual # or persons served in Section I A & B

Hispanic ethnicity is not a race

II. Rapid Re-Housing (RRH) Activities

(Use if Budget Includes RRH Cost Categories of Housing Relocation and Stabilization Services, Tenant-Based Rental Assistance and/or Project-Based Rental Assistance). If a client served in this report period was reported in a previous report period, that client should not be counted again.

Actual Number of Adults Served: _____

Actual Number of Children Served: _____

Don’t know/Refused/Other: _____

Missing Information: _____

Total _____

Actual Number of Households Served: _____

Total Persons Served with Rapid Re-Housing Activities (Section II)

Note: The numbers reported under Hispanic ethnicity should also be reflected in the Total column, as “Hispanic” denotes an ethnicity and not a race. (The federal government defines Hispanic as “a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race”.)

Race / Gender / # Total / # Hispanic
Male / Female / Transgender / Refused/Other / Missing Info
White
Black/African American
Asian
American Indian/Alaska Native
American Indian/Alaska Native & White
Asian & White
Black/African American & White
American Indian/Alaska Native &
Black/African American
Other Multi-Racial
Total - this total should match unduplicated actual # or persons served in Section II

Hispanic ethnicity is not a race

Rapid Rehousing Performance Measures

Category / Total
# Entered/Served
# Entered Case Management
# Received Rental Assistance
# Received Utility Assistance
# Transitioned to Permanent Housing
# Still in Shelter
# Transitioned to Non-Permanent Housing
Total

III. Homelessness Prevention (HP) Activities

(Use if Budget Includes HP Cost Categories of Housing Relocation and Stabilization Services, Tenant-Based Rental Assistance and/or Project-Based Rental Assistance). If a client served in this report period was reported in a previous report period, that client should not be counted again.

Actual Number of Adults Served: _____

Actual Number of Children Served: _____

Don’t know/Refused/Other: _____

Missing Information: _____

Total _____

Actual Number of Households Served: _____

Total Persons Served with Homeless Prevention Activities (Section III)

Note: The numbers reported under Hispanic ethnicity should also be reflected in the Total column, as “Hispanic” denotes an ethnicity and not a race. (The federal government defines Hispanic as “a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race”.)

Race / Gender / # Total / # Hispanic
Male / Female / Transgender / Refused/Other / Missing Info
White
Black/African American
Asian
American Indian/Alaska Native
American Indian/Alaska Native & White
Asian & White
Black/African American & White
American Indian/Alaska Native &
Black/African American
Other Multi-Racial
Total - this total should match unduplicated actual # or persons served in Section III

Hispanic ethnicity is not a race

Homeless Prevention Performance Measures

Category / Total
# Entered/Served
# Entered Case Management
# Received Rental Assistance
# Received Utility Assistance
# Retained Housing
# Transitioned to Alternative Permanent Housing
Total

IV. Street Outreach

Actual Number of Adults Served: _____

Actual Number of Children Served: _____

Don’t know/Refused/Other: _____

Missing Information: _____

Total _____

Actual Number of Households Served: _____

Total Persons Served with Street Outreach (Section IV)

Note: The numbers reported under Hispanic ethnicity should also be reflected in the Total column, as “Hispanic” denotes an ethnicity and not a race. (The federal government defines Hispanic as “a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race”.)

Race / Gender / # Total / # Hispanic
Male / Female / Transgender / Refused/Other / Missing Info
White
Black/African American
Asian
American Indian/Alaska Native
American Indian/Alaska Native & White
Asian & White
Black/African American & White
American Indian/Alaska Native &
Black/African American
Other Multi-Racial
Total - this total should match unduplicated actual # or persons served in Section IV

Hispanic ethnicity is not a race